Provider Demographics
NPI:1407376940
Name:HEROLD, JESSICA CHARLOTTE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:CHARLOTTE
Last Name:HEROLD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4836 VAN NUYS BLVD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-2101
Mailing Address - Country:US
Mailing Address - Phone:818-907-7546
Mailing Address - Fax:818-907-9506
Practice Address - Street 1:4836 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-2101
Practice Address - Country:US
Practice Address - Phone:818-907-7546
Practice Address - Fax:818-907-9506
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA54694363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant